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Abstract

Background: Approximately 10-20% of myocardial perfusion imaging (MPI) is performed for inappropriate indications. Established metrics of quality outpatient care for coronary artery disease (CAD), hypertension, and diabetes mellitus (DM) have similar, or worse, failure rates. The extent to which inappropriate use of MPI is associated with failure to achieve quality care metrics has not been investigated.

Methods: We conducted a cross-sectional investigation of MPI performed on outpatients at a single VA medical center between December 2010 and July 2011. Data were gathered from documentation of the visit when the MPI test was ordered, including metrics of quality care for outpatient management of hypertension, DM, CAD, and smoking. Goals of care were selected from established metrics of quality outpatient care. We also assessed whether the clinician documented a plan to bring the metrics to goal.

Results: 516 MPI patients were included, 52 (10.1%) inappropriate (I) and 464 (89.9%) appropriate or uncertain (A/U). Hypertension (82.2%), DM (41.3%), CAD (41.1%), and tobacco use (23.1%) were common. No significant differences between A/U and I cases were observed for CAD quality metrics (aspirin use, p=0.22; beta-blocker use, p>0.99; statin use, p>0.99; lipids at goal, p=0.20). While hemoglobin A1c levels were significantly lower for I cases (6.6% versus 7.5% for A/U cases, p=0.04), no difference was observed in the percent of patients at goal (62.5% for I versus 46.3% for A/U, odds ratio [OR] 2.90, 95% confidence interval [CI] 0.55-15.27, p=0.258). Blood pressure at goal (p=0.36) was not different. Use of tobacco was not different between the two groups (23.2% versus 15.7%, p=0.29), and neither was the proportion without tobacco cessation planning (0.65% versus 3.9%, p=0.08) Overall achievement of quality metrics was poor but similar to other reports of these metrics (CAD 44.8%, DM 47.9%, hypertension 73.1%, smoking 77.5%). Most clinicians documented a reason for not achieving, or a plan to achieve the metrics (CAD 95.3%, DM 68.2%, hypertension 90.8%, smoking 99.0%).

Conclusion: Overall, the inappropriate use of MPI is not associated with failure to achieve established metrics of quality outpatient care. On the contrary, most clinicians demonstrate awareness of these care deficiencies by documenting either a reason for not achieving, or a plan of care to achieve quality care metrics